AVM的诊断及治疗

AVM的诊断及治疗,何 爽,一、定义,是一种先天性局部脑血管发生学上的变异。在病变部位脑动脉和脑静脉之间缺乏毛细血管团，致使动脉与静脉直接相通，形成动静脉之间的短路。,二、病因,胚胎期血管生成调节机制发生障碍所致。 原始动、静脉仅有两层内皮细胞隔开，发育异常使动静脉不经过毛细血管网而直接相通。,三、流行病学,动静脉畸形的患病率约为 50/100，000。随着影像学技术的发展，未破裂动静脉畸形的检出率逐年升高，而破裂动静脉畸形的发病率一直维持稳定。动静脉畸形常发生在 20-40 岁之间的年轻人群中。,四、病理生理,1有一条或者多条供血动脉、畸形血管团、一条或多条引流静脉构成2供血动脉和畸形血管团可形成动脉瘤（8-12%），可见动静脉瘘3畸形血管团内血流缓慢易形成血栓，管壁发育不良易出血，管壁钙化，反复出血使病灶增大4局部脑组织软化、出血、钙化、萎缩、胶质增生,五、常见临床表现,1.出血 多发生于年龄较小者，可表现为蛛网膜下腔出血、脑内出血或硬膜下出血，常于体力活动或情绪波动后突然出现剧烈头痛、呕吐、意识丧失。2.癫痫 可见于40%50%的患者，约半数为首发症状，多见于较大的、有大量“脑盗血”的动静脉畸形者。3.头痛 60%的患者有长期头痛史，多局限于一侧，出血时头痛的性质发生改变。,六、影像学诊断,a、CT 未出血者：不规则稍高、低或混杂密度影，动静脉钙化、软化灶。 出血者：脑实质血肿、SAH、脑室内积血 增强可见供血动脉、血管巢、引流静脉强化,无特异性，结合患者年龄、高血压病史、家族史、其他部位血管瘤病史，进一步完善检查。,需要和高血压脑出血、淀粉样变性脑出血等做出鉴别。,CTA 优点：时间快,MR 团状、条索状、蜂窝状的血管流空影。无出血时首选3D-TOF。,MRA,DSA,七、治疗,a、切除手术 优点： 可清除血肿b、介入栓塞 优点：可保留功能区c、伽马刀,CASE,A 16-year-old girl presented with sudden headache on the morning of 2016, June 30. Prior to the admittance to the local hospital, she was given analgesic drug by her patients and no relief followed by and she progressively turned into lethargy.CT scan showed the left frontal lobe hematoma break into left ventricle, 3rd and 4th ventricles.,CTA demonstrated left frontal lobe AVM, feeded by the branch of left anterior cerebral artery, but the venous drainage was not very clear.,The patient was transferred to our hospital for further treatment, recheck CT and angiography were performed which showed more details.,3D-DSA provided more details to identify the feeders and program the roads for microcatheter approaching.,The patient was taken to the hybrid operation room, underwent preoperative embolization to minimize the risk of bleeding d